title: Improvement in emergency department length of stay using an early senior medical assessment and streaming model of care: A cohort study.
abstract: OBJECTIVE
  Australian EDs are required to conform to the National Emergency Access Target (NEAT): patients must be discharged within 4 h of arrival. The aim of the present study was to determine if a model of care called Senior Assessment and Streaming (SAS) would increase the proportion of patients achieving NEAT.
  
  
  METHODS
  Stable, ambulant patients considered to have problems that early consultant-level assessment was likely to improve processing efficiency were streamed through a dedicated clinical area staffed by an ED physician, intern and nurse. The proportion of patients achieving NEAT were compared between days with or without SAS, adjusted for confounding variables.
  
  
  RESULTS
  The 18 962 patients presented during the study, 6828 on days with SAS, 12 134 on days without. On days with SAS, there were more presentations, more admissions, lower access to ward beds and fewer staff working hours. After controlling for confounding, the odds of meeting NEAT on days with SAS was 15% higher compared with days without (odds ratio, 1.15; 95% confidence interval [CI], 1.07-1.24; P < 0.001). For the subgroups of patients admitted, discharged, triage category 3, 4, 5, or presentation 12.00-18.00 the odds of meeting NEAT on days with SAS was, respectively, 1.10 (95% CI, 0.98-1.23; P = 0.10), 1.17 (95% CI, 1.07-1.28; P < 0.001), 1.17 (95% CI, 1.08-1.27; P < 0.001) and 1.19 (95% CI, 1.06-1.35; P = 0.003). The odds of a patient not waiting to be seen on days with SAS was 28% lower compared with days without (odds ratio, 0.72; 95% CI, 0.58-0.90; P = 0.003).
  
  
  CONCLUSIONS
  Through the introduction of SAS, the present study has demonstrated that providing early senior medical assessment can improve an ED's ability to meet NEAT.
authors.affiliation: Emergency Department, St George Hospital, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
authors.forename: Stephen Edward
authors.initials: SE
authors.lastname: Asha
authors.forename: Allan
authors.initials: A
authors.lastname: Ajami
mesh_terms: D000328:Adult; D000368:Aged; D001315:Australia; D015331:Cohort Studies; D017598:Efficiency, Organizational / Q000592:standards; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000592:standards; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010351:Patient Discharge; D011446:Prospective Studies; D013997:Time Factors; D055815:Young Adult
keywords: access block; emergency department; length of stay; model of care; streaming